Division of Labor Standards Permit and Certificate Unit Harriman State Office Campus Building 12, Room 185B Albany, NY 12240 www.labor.ny.gov Application for Employment Agency License Use this form to apply for an Employment Agency License. Answer all questions. Attach additional sheets as needed. • Mail the signed application to the address above. • Be sure to include all the required information and documents listed on page 4. • Once licensed, any change to the agency name, address, manager, ownership, partners, officers or stockholders requires prior approval by the Department of Labor for the license to remain valid. 1. Name agency will do business under: 2. Agency location: Street number and street: City, Town, Village: County: Zip: 3. Agency phone number: 4. Federal Employer Identification Number (FEIN): 5. Main type of placements: 6. Number of placement employees expected: (Note: Placement employees are those who spend a large part of their time interviewing, counseling or talking with job applicants for the purpose of placing or procuring a job.) 7. Type of Owner (check one): Sole proprietor Partnership Corporation 8. List the name, address, title and phone number of: • The owner, if a sole proprietor • Each partner, if a partnership • All officers, if a corporation, and each stock-holder owning 10% or more stock, if not publicly traded Applicant’s Name and Home Address Title Home Phone 9. For each person in item 8, list all the business activities they engaged in for the five years before this application’s date. Date Date Name of Person Name and Address of Firm Activity Started Ended LS 355 (09/18) (Complete all pages.) Page 1 of 4 10. Did anyone listed in item 8 have any license to conduct business denied, cancelled, suspended, revoked, or surrendered? Yes No If “Yes,” give details and reasons. Name of Date of Name and Address of Business Nature of Reason for Denial, etc. Person Action (City, Town, Village, State) Business 11. Was anyone in item 8 ever convicted of a crime or offense other than a traffic infraction? Yes No If “Yes,” give details and reasons. Name of Person Offense Date Convicted City, Town, Village Penalty 12. Give the name of the person who will direct and operate the placement activities of the agency: Note: If this person is not listed in item 8, submit an “Application for Agency Manager Permit,” LS 355.2 and skip item 13. It does not need to be answered. 13. Work history: Give a detailed list of each employer you worked for as a placement employee, vocational counselor, or in related activities; include self-employment. • Duties: List Percent (%) of Time Spent on: a) interviewing and counseling applicants b) screening, selecting and placing applicants Employer Name and Address Date Date c) soliciting and obtaining job orders (List the last employer first.) Started Ended d) preparing job descriptions, etc. e) non-related duties • Give Name and Title of Immediate Supervisor. LS 355 (09/18) (Complete all pages.) Page 2 of 4 14. Will applicant recruit people from outside the state for employment as domestic or household employees? Yes No If “Yes,” give details regarding each emigrant agent and submit a photocopy of each licensed emigrant agent’s license. Name and Address of Emigrant Agent License Expiration Name, Address and Title Include country, if not operating in the US Number Date of Issuing Official 15. Does applicant intend to provide or arrange for lodging for applicants for employment or for people doing business with the agency? Yes No If “Yes,” give details for each location. Name and Address of Premises Where Lodging will be Furnished Phone Name of Person in Charge 16. Does applicant provide hospitalization insurance for domestics or household employees from overseas? Yes No If “Yes,” give name of insurance company and policy number. Insurance company name: Policy number: 17. I swear the statements made in this application are true and accurate under the penalties of perjury. If sole-proprietor, signature of owner. If a corporation, signatures of president and treasurer. If a partnership, signatures of all partners. Attach addition sheets as needed. Applicant’s Signature(s) Title Date All information and material submitted is subject to investigation by this Department. LS 355 (09/18) (Complete all pages.) Page 3 of 4 Be sure to include the following information and documents with your application. Missing information or documents may result in delays or your application could be denied. 1. A surety bond naming the “People of the State of New York” as obligee. The penal sum is $5,000, unless the agency is a modeling agency or agency engaged in recruiting domestic or household employees from outside the continental United States, then the penal sum of $10,000 is required. 2. Two statements of character (LS 361) for each person listed in item 8. 3. Fee: Check or money order for the required fee, payable to the Commissioner of Labor (see LS 355.3 for fees). 4. Two samples each of: • Applicant Contract • Terms and Conditions • Receipt, and • Each form that an applicant for employment is required to execute 5. Emigrant Agent’s License: Photocopies of each licensed emigrant agent’s license (see item 14). 6. A certified copy of certificate of doing business filed with the county clerk, if sole owner or partnership, or A photocopy of corporate filing receipt filed with Secretary of State, if a corporation 7. From your insurance company a completed: • C-105.2, proving workers’ compensation insurance coverage, and • DB-120.1, proving disability insurance coverage (Other acceptable forms of proof: U-26.3 from SIF; if self-insured, SI-12 or GSI-105.2 for WC and DB-155 for disability.) Or, if you are not liable for Workers’ Compensation and/or disability insurance, a completed: • CE-200 form. This form is available at www.wcb.ny.gov. Click on “WC/DB Exemptions,” then click on “Request for WC/DB Exemption.” You may contact the Workers’ Compensation Board at 866-298-7830 for help getting this form. When calling, wait until after the menu finishes for someone to help you. 8. Corporate minutes: If a corporation, a conformed or photocopy of corporate minutes showing election of officers. 9. Fingerprint receipt: A copy of your receipt from Morpho Trust USA for the required reports on fingerprint search and verification of each person listed in item 8 of this application. • Note: The actual reports must be submitted to this office by Morpho Trust USA to complete your application. See accompanying “fingerprinting” sheet, LS-358, for instructions including fees. Important: Any change to the agency name, address, manager ownership, partners, officers or stockholders requires prior approval by the Department of Labor for the license to remain valid. LS 355 (09/18) Page 4 of 4 .